Acne


Acne Overview
  • Acne may affect any age group, but it is most common in adolescents
  • Lesions consist of noninflammatory comedones (whiteheads and blackheads) and inflammatory papules, pustules, nodules, and cysts.
    • Comedones are non-inflammatory acne lesions.
    • Inflammatory lesions include
      • Papules,
      • Pustules, and
      • Nodules.
  • Severity ranges from mild comedonal acne to severe nodulocystic acne, which can be permanently disfiguring.
  • Systemic effects may also be present with acne fulminans, a rare variant.
History & Exam
  • Skin lesions:
    • Closed comedones (whiteheads)
    • Open comedones (blackheads)
    • Nodules or papules
    • Pustules (“cysts”)
    • Scars: ice pick, rolling, boxcar, atrophic macules, hypertrophic, depressed, sinus tracts
  • Skin tenderness
  • Depression, social isolation
  • Systemic complaints
Diagnostic Tests
  • Clinical diagnosis
  • Hormonal evaluation
  • Bacterial culture
Treatment
  • Grading acne based on the type of lesion and severity helps guide therapy.
  • Comedonal acne  – Keratinolytic agent (eg, Retin-A)
  • Mild inflammatory acne – Keratinolytic agent +/- Benzoyl peroxide/topical antibiotic
  • Moderate inflammatory acne – Benzoyl peroxide/topical antibiotic +/- systemic antibiotic
  • Severe (nodulocystic) acne – Isotretinoin
  • Topical Retinoids:
    • Prevent the formation of comedones and reduce their number, and are indicated as monotherapy for noninflammatory acne.
    • Tretinoin topical : (0.01 to 0.1%) children >12 years of age and adults: apply to the affected area(s) once daily before bedtime or on alternate days
       
  • Topical antibiotics:
    • Used primarily for the treatment of mild to moderate inflammatory or mixed acne.
    • Clindamycin topical : (1% foam) children >12 years of age and adults: apply to the affected area(s) once daily; (1% gel, lotion, pledget or solution) children >12 years of age and adults: apply to the affected area(s) twice daily or
    • Erythromycin topical : (2%) children and adults: apply to the affected area(s) twice daily or
    • Dapsone topical : (5%) children >12 years of age and adults: apply to the affected area(s) twice daily; reassess if no improvement in 12 weeks
       
  • Oral antibiotics
    • Effective for the treatment of moderate to severe acne.
    • Doxycycline : 50-100 mg orally twice daily for 2-3 months, followed by 50-100 mg once daily for 1-2 months
      • Do not use in children < 8 years old
    • Trimethoprim/sulfamethoxazole : 160/800 mg orally twice daily for 2-3 months, followed by 160/800 mg once daily for 1-2 months
       
  • Oral Hormone:
    • Hormone-related (female, not pregnant): women experiencing acne flares associated with menstrual periods; they should be pursued only if other treatments are ineffective.
    • Combined oral contraceptives
      • Tri-Sprintec
      • Ethinyl estradiol +
        • Norgestimate (eg, Ortho Tri-cyclen)
        • Norethindrone (eg, Estrostep)
        • Levonorgestrel (eg, Alesse)
        • Drospirenone (eg, Yaz, Yasmin)
    • Spironolactone : 25-200 mg orally once daily for 3-6 months
       
  • Oral isotretinoin
    • Reserved for treatment of severe, recalcitrant acne.
    • Isotretinoin : children >12 years of age and adults: 0.5 to 1 mg/kg/day orally for a total of 5-6 months
      • In the US, isotretinoin can only be prescribed through the iPledge system.
      • Providers, pharmacies, and patients must register with the system in order for the drug to be prescribed.
      • The program is aimed at decreasing the number of birth defects associated with this medication

 

Referral
  • Consider referral/consultation to dermatologist when:
    – Refractory lesions despite appropriate therapy
    – Consideration of isotretinoin therapy
    – Management of acne scars
 


Papules

Comedo

Comedonal acne

Nodulocystic:
Nodulocystic acne

Scaring Acne:
Scarring acne

 

Source: ITE 2013 Q 51

51. A 14-year-old male has open and closed comedones without evidence of surrounding inflammation on his face and upper back. Which one of the following is the most appropriate initial treatment?
A) Topical antibiotics
B) Topical retinoids
C) Oral antibiotics
D) Oral isotretinoin